Tuesday, March 25, 2014

How can one disease be so vast?Actually, it really isn’t one disease; there
are hundreds of variations: Prostate cancer can be slow or fast growing,
responsive or unresponsive to treatment, metastasizing early or not
metastasizing at all.In fact, selecting
treatment for prostate cancer would be simpler if these extreme “either-or” types
of examples I just cited were common. In reality, most men’s cases are not so
extreme, they lie somewhere in the middle. Selecting the best treatment, one that matches
each variety of prostate cancer, is a really big challenge. Therefore, the
process begins by trying to understand the disease as well as we can.Characterizing
the DiseasePeople often assume that differences in the way cancer
behaves—life threatening vs. benign—comes from observing the same illness at different time points.What’s often misunderstood is that distinct varieties of prostate cancer also
exist. It’s not all one disease. This
doesn’t mean that the stage of disease is unimportant. It’s just not the whole
picture.Patients frequently ask, “Am I
stage A, B, C, or D?” without realizing the lettering system is just a
description of what the surgeon feels during his finger exam. PSA and the
Gleason grade are just as important as the stage of the disease. What can
be confusing is that no single element comprehensively defines the disease. For
example, one man with a higher PSA may do well while another man whose PSA is
low may do poorly.A Widely-Accepted
Classification SystemTherefore, a classification system to
help predict cancer aggressiveness requires a “grid” that incorporates
multiple prognostic elements—the letter-stage, PSA, Gleason and scan results.Dr. Anthony D’Amico from Harvard is credited with developing the modern
system that uses PSA, Gleason and stage to divide newly-diagnosed prostate
cancer into low, intermediate and high-risk categories.Building on the D’Amico system, and to
further highlight the differences between categories, the Prostate Cancer
Research Institute (PCRI) has named the risk categories with different Shades of Blue* and expanded the grid to
include two more categories: men with disease relapsed after treatment with a
rising PSA and men with metastatic disease or disease that has become resistant
to hormonal therapy.The Five Shades of
Blue:

Sky for low-riskTeal for intermediate-risk

Azure for high-risk

Indigo for PSA-relapsed disease after
treatment

Royal for men with metastases or hormone
resistanceDoes the system separate men into
distinct categories?Yes. For example,
in a study published by Dr. Timothy Wilt in the New England Journal of Medicine,
731 men volunteered between 1994 and 2002 either to have immediate surgery or
observation alone.The subsequent
outcome showed higher cancer mortality with in men in a higher-risk (Azure)
category compared to Sky or Teal. It also showed an 8% improvement in ten-year
survival rates for men in the Azure category when they underwent surgery
(rather than observation).Surgically-treated, intermediate-risk men (Teal) showed a 10% reduction
in the incidence of metastases compared to the men who did not have surgery.
Men in the low-risk category (Sky) showed no difference in mortality or
metastases with or without treatment. Dr. Wilt’s study, therefore, went beyond
merely validating the predictive ability of the D’Amico staging system. The
study also provided a measure of the degree
of benefit associated with doing surgery.General
Treatment RecommendationsWhile there are no
absolute rules for treatment, as a starting point, here are some general
guidelines:Sky (low-risk): observation or monitoring
with active surveillance

Teal (intermediate-risk): monotherapy,
limiting treatment to a single
therapy such as IMRT or surgery or brachytherapyAzure (high-risk) combination therapy with
IMRT, brachytherapy and hormone blockade

Indigo (relapsed-disease): Treatment
intensity tailored to the location in the body of the relapsed disease and to
the PSA doubling time rateRoyal (advanced-disease): Multimodality
immunotherapy, hormonal therapy, chemotherapy and radiation sequentially or in
combination

The message is that before treatment
can be selected what we are treating needs to be accurately defined.The starting point, therefore, is to begin
with dividing prostate cancer into five broad categories or Shades of Blue.By doing this, the number of treatment
options can be narrowed down and finding the right treatment becomes easier.

Tuesday, March 18, 2014

RALPH BLUMAs I wrote
in my last blog, once your family doctor has referred you to a local urologist
and you have been diagnosed with prostate cancer, your first and most important
decision is choosing a doctor with the necessary skill and experience to help
you weigh all your options and determine your best course of action.
This doctor may not be your community
urologist.Provided
the cancer is still contained within the prostate gland, and provided there is
no medical reason surgery is contraindicated, your urologist (who is a surgeon)
will almost certainly recommend it. And in your emotionally vulnerable state,
and with a natural desire to just get rid of the cancer, it is quite likely you
will uncritically take his advice, without question or research.After
talking with your urologist you may come away with the impression that prostate
cancer surgery is fairly straightforward. It is not. Anatomically, the prostate
is in absolutely the wrong place for a simple surgical procedure. Located as it
is within millimeters of the bladder and the rectum, there is zero tolerance
for a slip of the scalpel. To make matters worse, there is prolific venous
blood supply surrounding the gland, and on a bad day even the best surgeons can
end up operating in a pool of blood, and with restricted ability to see clearly
in order to spare the miniscule nerves (thinner than a human hair) that control
erections. With such an intricate and complex procedure the high rates of
impotence are hardly surprising.So much
skill is required to successfully perform a radical prostatectomy that being
operated on by less than the very finest surgeons dramatically increases the
chances for a poor outcome. Levels of ability vary widely from surgeon to
surgeon even in prestigious university centers. In 2004, Dr. Peter Scardino,
Chief of Urology at Memorial Sloan-Kettering, published a study documenting the
differenced in “talent” in this unregulated field. The study evaluated the
surgical skill of twenty-six urologists on staff at Sloan-Kettering and
Baylor. The indicator used to measure skill was the frequency of leaving
cancer behind after the operation (the technical term is “positive surgical
margin”). The study reported that the best doctor in the group left cancer
behind in 10% of his cases. The positive margin rates of the other twenty-five
urologists ranged from 11% to a shocking 48%.

Despite
these disturbing statistics surgery is still the primary treatment of choice
for those diagnosed with prostate cancer. Yet while a select few surgeons
perform dozens, perhaps a hundred or more procedures, generally speaking, the
average urologist performs fewer than half a dozen prostate operations a year.
In the U.S. there are somewhere around 70,000 radical prostatectomies done
annually, and there are 10,000 urologists. If you do the math it’s clear that
your community urologist is probably not doing enough prostate surgeries to
stay proficient.

So buyer
beware. Before you consent to surgery be sure to ask your urologist how many
nerve-sparing prostatectomies he has performed--it should be at least 50. Preferably
upwards of 200. Did often he get positive surgical margins? What percentage of
the men he operated on are sexually potent a year after the procedure? What
percentage suffers from incontinence a year later? And if you are over 70 years
old and your urologist is recommending surgery, find another urologist, or
better still, a prostate oncologist.

I hope this short
essay has helped convey the importance of not rushing into treatment.It bears repeating: Go slowly. Do your
homework. I have avoided surgery for almost 25 years. Consider the options,
including—since surgery is only right for some
of you—“Do nothing,” which for many men translates as “Die with prostate
cancer, not from it."

Tuesday, March 11, 2014

Prostate
cancer is by far the most hormonally sensitive cancer. Practically all other
types of cancer, except breast cancer, are totally immune to testosterone
blockade. Just as normal cells need oxygen, prostate cells, cancerous or
otherwise, depend on testosterone. Cells originating in the prostate are by
nature very sensitive to testosterone blockade. This sensitivity can be
exploited as a treatment. When a cancer cell is deprived of testosterone it
initiates a suicide sequence called apoptosis. Low testosterone is acting like
a signal, sending a biochemical message to the cell, telling it to release
destructive intracellular enzymes, causing it to die.Within
a few months of blocking testosterone, cancer regression is usually dramatic. For
example, one study used Zytiga prior to surgery. The surgically removed
prostate glands were fine-sliced and examined under a microscope.Some men showed no residual cancer in their prostates.

The
testosterone inactivating pharmaceuticals (TIP) that block testosterone are
listed below in order of ascending potency:

While categories
6 and 7 are clearly the most potent, as yet there is no conclusive evidence
that either of these two categories is more potent than the other. However, a
variety of studies have demonstrated that a combination
of agents is more potent that agents used by themselves.

Also,
a number of studies have shown that men live longer when they are treated with
TIP at an earlier stage—that is, at the time of diagnosis—rather than at the
time of relapse when the disease has become more entrenched:In August 1997, The New England Journal of
Medicine published a study comparing two groups of 200 men each, all of whom
were treated with radiation for high grade prostate cancer (Gleason 8, 9, or 10
or a large tumor felt on digital rectal exam). The five-year death rate from
prostate cancer was reduced by 80% in the men who received radiation plus TIP compared to radiation alone.

A
study published in the British Journal of Urology in February 1997 looked at
immediate TIP vs. starting TIP after the cancer was causing symptoms.Two groups of 400 men were evaluated and
compared. Mortality was 25% lower in the group that had early treatment.A third study was published in the Journal of
Urology in June 1998 in which ninety-one men were randomized between radiation
alone and radiation with TIP.The
mortality rate was 50% less in the men that were treated with TIP.

Another
famous study in New England Journal of Medicine authored by Dr. Messing in 1999
looked at the value of starting TIP right after surgery in a 100 men, all of
whom had cancer confirmed to have spread into their lymph nodes. Half were
randomly allocated to start TIP right after the operation.The other half started TIP when they had
disease recurrence and evidence of progression.Seven years later the men treated with immediate TIP were eight times less likely to have died of
prostate cancer: Two men treated with immediate TIP died of prostate cancer
whereas 17 men treated with delayed TIP died of prostate cancer.

In
this last study TIP was continued for life. Since we know that TIP has more side
effects when administered over a longer period, one can’t help but wonder if
the same survival advantage could have been achieved with a shorter treatment
period, say for two years?

The side effects of TIP
can indeed be troublesome, especially the lowering of libido.In our experience 70% of men under age 60 and
90% of men over age 65 lose sexual desire completely—particularly if they are
treated with drugs in category three or higher. Category two and category one
drugs cause loss of libido in about 50% and 25% of men respectively.

It is important to make
one thing clear: Libido is not a euphemism for getting an erection. Viagra is
powerful enough to restore erections in most men on TIP. Loss of libido means undergoing a loss of sexual interest. After TIP is stopped, younger
men recover libido quite nicely though a minority describe their libido as
persistently diminished. Some men, particularly the older ones, are more likely
to have a persistent reduction in libido.

The list of potential
side effects from TIP (besides libido problems) is long. Most of the side
effects are manageable with expert supervision. Please inquire about a copy of Preventing the Side Effects of TIP for
further details. Using a category two drug like Casodex is one way to reduce
TIP’s side effects. However, using a
less potent agent raises another concern: Some studies have shown reduced
anticancer efficacy. Clearly treatment selection depends on weighing the
intensity of potential side effects against the expected survival benefit. In
some cases, slightly diminished anticancer efficacy may be an acceptable
tradeoff if side effects can be substantially reduced.

Prostate cancer’s Achilles heel
is that it can’t survive without testosterone. While anti-testosterone
medications have remarkable anticancer efficacy they can also cause notable
side effects. Treatment intensity and timing needs to be varied in accordance
with each patient’s individual characteristics.

Tuesday, March 4, 2014

BY RALPH BLUMLife
is full of risks, but if you are one of the legion of men with prostate cancer
whose urologist is recommending a radical prostatectomy, make sure you have
considered the following risks of collateral damage:Incontinence: Urinary
leakage is usually a temporary problem after a prostatectomy, but even the best
urologists report that about 7% of their patients are left with permanent and
constant urinary drainage. Less skilled surgeons have much higher rates.
After surgery, most men experience some minor leakage when they cough, lift,
bend over, or laugh.Another
problem is the formation of scar tissue in the urethra, the passage from the
bladder to the penis. The suture site where the severed urethra is reconnected
can become constricted by scar tissue that blocks the flow of urine. This may
be correctable with urethral dilation, a process forcing oversized, stainless
steel probes up the penis to stretch out the ring of rock-hard tissue.
Unfortunately, scar tissue is notoriously uncooperative, often refusing to
stretch at all. In some cases the stretching fractures the brittle ring of
tissue, resulting in permanent incontinence. If that happens, another operation
is required to implant an artificial sphincter.Impotence:Without
nerve-sparing surgery permanent erectile dysfunction is virtually inevitable.
With nerve-sparing surgery, the best surgeons hope to be able to save the nerve
bundles (located very close to the back of the prostate on both sides) that control
erections. If both sides of the nerve bundles can be saved, potency is around
40% to 75% in patients under 70 years old (depending on which expert you
consult, and the patient characteristics). If only one side of the nerve
bundles can be saved, potency drops to around 25% to 45%. However, until the
doctor actually performs your surgery, he won’t know whether he can spare the
nerve bundles.Even
men who recover their erections after surgery undergo a prolonged period of
impotence, often lasting up to a year or more.
During this time of enforced abstinence, as with any unused muscle, atrophy of
the penis occurs. This means that of the men who end up recovering some degree
of erectile function, only 5% report that their erections are as good as before
surgery. Additionally, despite claims from urologists who maintained for
years that patients’ complaints of penis shrinkage were anatomically
impossible, diligent researchers have finally collected the necessary
measurements showing that shrinkage is common. The average amount is about
one-half inch, although some men undergo considerably greater shrinkage.Studies
show that impotence can totally redefine a man’s self-esteem, his
self-confidence and his relational satisfaction. In some cases Viagra can help
with surgically induced impotence. However, penis vacuum devices, penis
tourniquets, penis injections (yes, with needles) or the surgical implantation
of a plastic rod into the penis is often required to restore function. In my
case, lead me to the monastery!Other
Rare but Possible Risks from Surgery:

Significant blood loss requiring transfusions

Pain from surgery

Blood clots in the legs

Heart Attack

Infection

Temporary or permanent memory loss from anesthesia

Miscellaneous surgery-related problems

So
with these considerable risks, what is the pay-off for undergoing surgery? The
major pay-off is, if you are lucky and have a successful nerve-sparing
prostatectomy, it will cure the cancer and you will suffer minimal
collateral damage. The only other advantage is you get a better idea of how
serious your cancer is because the pathologist evaluates the prostate after its
removal. If he finds that the cancer has spread even a little, you and your
doctor can decide what to do next.

No
one knows for sure which prostate cancer treatment gives a better chance for
cure or a better quality of life. But if you decide to go with a prostatectomy,
make sure that the surgeon you are considering is experienced and skilled in
the procedure.

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PROSTATE SNATCHER VIDEOS

MARK SCHOLZ, MD

Mark Scholz, MD is board certified in medical oncology and internal medicine. He has been treating men with prostate cancer exclusively since 1995. He is the Medical Director of Prostate Oncology Specialists, Inc., and Executive Director of the Prostate Cancer Research Institute. He is an acknowledged expert on management and treatment for prostate cancer using hormone intervention, immunotherapy, chemotherapy and angiogenesis as well as vitamin, herbal and other forms of lifestyle counseling. His affiliations include St. John's Health Center, Marina del Rey Hospital and others. Dr. Scholz also served as an associate clinical professor in the department of Oncology at USC School of Medicine. Dr. Scholz volunteers for the Internet list “Patient to Physician,” found via Resources at www.pcri.org . You may also find current posts on twitter. www.twitter.com/markscholzmd

RALPH H. BLUM

Ralph H. Blum is a cultural anthropologist and author, graduated Phi Beta Kappa from Harvard University with a degree in Russian Studies. His reporting from the Soviet Union, the first of its kind for The New Yorker (1961—1965), included two three-part series on Russian cultural life. He has written for various magazines, among them Reader’s Digest, Cosmopolitan, and Vogue. Blum has published three novels and five nonfiction books. He has been living with prostate cancer, without radical intervention, for twenty years.

PROSTATE ONCOLOGY SPECIALISTS

Established in 1995, Prostate Oncology Specialists has earned national acclaim for its comprehensive approach to prostate cancer prevention and management. Under the direction of Medical Director Mark Scholz, M.D., Prostate Oncology Specialists employs a highly skilled team of physicians trained in oncology, radiology, hematology, and internal medicine who treat all stages of prostate cancer. Prostate Oncology Specialists are not wedded to any single therapy for prostate cancer, but rather advocate the exploration of treatment options that are customized and tailored to the unique needs of each individual patient. Treatments employed include active surveillance, testosterone deprivation, partial cryotherapy, seed implantation, intensity-modulated radiation, and surgery. Prostate Oncology Specialists’ ongoing mission is to uncover new medical breakthroughs in the treatment and management of prostate cancer.

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